Aeromedical Disposition Note (Fit for Flight/Duty)

Date/Time: [Encounter date and time]

Location: [Clinic/facility]

Clinician: [Name, credentials, and aeromedical role]

Encounter Type: [Return-to-flight evaluation / Initial clearance / Post-event reassessment / Waiver-related evaluation / Periodic review] — [In-person / Telehealth]

Reason for Evaluation: [Trigger for evaluation]

(This is a focused operational-clearing note. Include only information material to safety, performance, and regulatory decision-making. Every clearance or restriction must be traceable to documented symptoms, exam findings, test results, and operational context. If key information is missing or results are pending, default to deferred clearance or grounding. Omit non-applicable sections; Disposition must always contain an explicit decision.)

Operational Context

Duty Category: [Pilot / Aircrew / ATC / UAS operator / Other safety-critical role]

Current Flight/Duty Status: [Actively flying / Grounded / Restricted] — [Effective date of current status]

Mission-Relevant Risk Factors: [Factors that materially affect risk for this case] (Include only if applicable: single-pilot ops, ejection seat, night/NVG, shipboard, high altitude, austere/remote operations, or other specific environmental exposures.)

Relationship Disclosure

(Include only for third-party or command-directed evaluations, not routine treating-clinician care.)

[Nature of evaluator role, disclosure boundaries, and confirmation member was informed]

Information Sources

[Records and sources reviewed with dates; diagnostic studies; specialty consultations; occupational/aeromedical records; collateral information] (If critical data are unavailable, explicitly state what is missing and impact on disposition.)

Clinical History

Condition(s) Under Evaluation: [Primary diagnosis/problem(s)]

• Onset: [Date]
• Treatment timeline: [Treatment initiation and changes with explicit dates]
• Symptom trajectory: [Improving / Stable / Intermittent / Worsening] — [Brief course summary]
• Last symptomatic episode: [Date and severity]
• Recurrence history: [Prior episodes with dates/frequency]

Aeromedically Relevant Symptoms: (Include only if the condition has potential for incapacitation, cognitive impairment, sensory effects, or sudden recurrence. Cover relevant domains: syncope/presyncope, seizure-like activity, vertigo/vestibular symptoms, chest pain/dyspnea/palpitations, sleep/fatigue, concentration/memory/psychomotor changes, vision/hearing changes.)

[Pertinent positive and negative symptoms with dates of last occurrence]

Current Functional Status: [Attention, reaction time, sustained vigilance, physical tolerance, any on-duty performance decrement or near-incapacitation episodes]

Medications and Treatment

• [Medication name, dose, schedule, indication, start date, side effects reported] (Repeat for each medication including OTC, supplements, PRNs, and sleep aids.)
• Treatment adherence: [Adherence status and barriers if any]
• Non-pharmacologic therapies: [CPAP, PT, psychotherapy—regimen and objective adherence data if available]
• Medication reconciliation: [Complete / Incomplete] (If incomplete, document as safety-critical gap and defer clearance.)

Objective Findings

• Vital signs: [Values] (Include only if relevant to the condition.)
• Focused exam: [Pertinent positives and negatives for neurologic, cardiac, vestibular, musculoskeletal, or mental status as applicable]
• Diagnostic results: [Test name, date, key metrics, interpretive conclusion] (Name the specific finding supporting disposition.)
• Specialty consultations: [Conclusions with dates]
• Pending results: [Test name and expected completion date] (If clearance depends on pending results, disposition should reflect deferral.)

Aeromedical Assessment

(Organize by problem in order of highest operational risk.)

[Problem 1]: [Diagnosis or differential]

• Status: [Resolved / Improving / Stable / Unstable / Controlled / Not controlled]
• Aeromedical concerns: [Sudden incapacitation risk, subtle performance decrement, cognitive/behavioral effects, distraction/pain, recurrence risk, medication-aviation physiology interactions]
• Objective evidence: [Specific findings, test results with dates, consultation conclusions supporting status determination]
• Prognosis: [Expected timeline for return to full duty]

Risk Assessment: (Include when there is sudden incapacitation potential, CNS-active medications, post-hospitalization status, or waiver considerations.)

• Hazard: [Specific hazard being prevented]
• Likelihood: [Estimated recurrence/impairment probability within operational timeframe]
• Severity: [Consequence given mission context]
• Mitigations: [Restrictions, monitoring, crew pairing, other controls]
• Residual risk: [Acceptable / Not acceptable]

[Problem 2]: [Diagnosis or differential]

(Repeat structure for additional problems as needed.)

Disposition

Decision: [Medically Cleared for Flight/Duty / Cleared with Restrictions / Not Medically Cleared (Grounded)]

(Select one and complete the corresponding section below. Decision must be explicitly supported by documented findings.)

If Medically Cleared for Flight/Duty:

• Effective date: [Date]
• Cleared for: [Duty category and platform/environment]
• Clinical basis: [Summary of evidence supporting clearance—symptom status, absence of impairing side effects, objective data]
• Required follow-up: [Details] (Does not restrict current status.)

If Cleared with Restrictions:

• Effective date: [Date]
• Operational restrictions: [Flight ops: no solo / dual controls required / no night-NVG / altitude limit / no ejection seat] [Duty: no weapons / no driving / no shift work] [Physiologic: no hypobaric exposure / hydration requirements] [Medication-related: no-duty window after dosing / grounded during titration]
• Duration: [End date or criteria for lifting]

If Not Medically Cleared (Grounded):

• Effective date: [Date]
• Expected duration: [Timeframe if known]
• Reason: [Unstable symptoms / Pending tests / Medication titration / Side effects / Other specific reason]

Return-to-Flight Criteria

(Include whenever member is grounded or restricted.)

To be cleared, the member must meet ALL of the following:

• Clinical: [Required symptom-free interval, specific symptoms that must resolve]
• Treatment: [Stable medication dose duration, no impairing side effects, documented adherence]
• Objective: [Required tests/consultations with acceptable thresholds]
• Observation period: [Duration and monitoring requirements if applicable]
• Clearing authority: [Flight medicine / Higher-level review / Waiver authority]
• Self-grounding triggers: [Symptoms requiring immediate removal from duty and re-evaluation]

Follow-Up Plan

[Follow-up interval and responsible clinic; repeat testing with target dates; contingency instructions if symptoms recur; documentation member should bring to next evaluation]

Patient Counseling

[Condition-specific operational risks discussed; medication precautions and timing; self-grounding expectations and reporting requirements; patient understanding and agreement] (If command was notified, document what operational information was communicated and that member was informed.)

Signature

[Clinician name, credentials, aeromedical role]

[Countersignature line if required by local policy]

(Administrative communications to command should contain only minimum necessary operational information—status, restrictions, duration—without protected health information.)